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The following is a guest blog post by Abhinav Shashank, CEO & Co-founder of Innovaccer.
Former US President Abraham Lincoln once said, “Give me six hours to chop down a tree and I’ll spend four hours sharpening the ax.” After having a look at the efficiency of the US healthcare system, one cannot help but notice the irony. A country spending $10,345 per person on healthcare shouldn’t be on the last spot of OECD rankings for life expectancy at birth!

Increasing Troubles
A report from Commonwealth Fund points out how massive the US health care budget is. Various US governments have left no stone unturned in becoming the highest spender on healthcare, but have equally managed to see most of its money going down the drain!

The US is 3rd when it comes to public spending on health care. The figure is $4197 per capita, but it covers only 34% of its residents. On the other hand, the UK spends only $2,802 per capita and covers 100% of the population!

With $1,074, US has the 2nd highest private spending on healthcare.

In 2013, US allotted 17.1% of its GDP to healthcare, which was the highest of any OECD country. In terms of money, this was almost 50% more than the country in the 2nd spot.

In the year 2013, the number of practicing physicians in the US was 2.6 per 1000 persons, which is less than the OECD median (3.2).

The infant mortality rate in the US was also higher than other OECD nations.

68 percent of the population above 65 in the US is suffering from two or more chronic conditions, which is again the highest among OECD nations.

The major cause of these problems is the lack of knowledge about the population trends. The strategies in place will vibrantly work with the law only if they are designed according to the needs of the people.

What is Population Health Management?
Population health management (PHM) might have been mentioned in ACA (2010), but the meaning of it is lost on many. I feel, the definition of population health, given by Richard J. Gilfillan, President and CEO of Trinity Health, is the most suitable one.

“Population health refers to addressing the health status of a defined population. A population can be defined in many different ways, including demographics, clinical diagnoses, geographic location, etc. Population health management is a clinical discipline that develops, implements and continually refines operational activities that improve the measures of health status for defined populations.”

The true realization of Population Health Management (PHM) is to design a care delivery model which provides quality coordinated care in an efficient manner. Efforts in the right direction are being made, but the tools required for it are much more advanced and most providers lack the resources to own them.

Countless Possibilities
If Population Health Management is in place, technology can be leveraged to find out proactive solutions to acute episodes. Based on past episodes and outcomes, a better decision could be made.

The concept of health coaches and care managers can actually be implemented. When a patient is being discharged, care managers can confirm the compliance with health care plans. They can mitigate the possibility of readmission by keeping up with the needs and appointments of patients. Patients could be reminded about their medications. The linked health coaches could be intimated to further reduce the possibility of readmission.

Let us consider Diabetes for instance. Many times Diabetes is hereditary and preventive measures like patient engagement would play an important role in mitigating risks. Remote Glucometers, could be useful in keeping a check on patient sugar levels at home. It could also send an alert to health coaches and at-risk population could be engaged in near real-time.

Population Health Management not only keeps track of population trends but also reduces the cost of quality care. The timely engagement of at-risk population reduces the possibility of extra expenditure in the future. It also reduces the readmission rates. The whole point of population health management is to be able to offer cost effective quality-care.

The best thing to do with the past is to learn from it. If providers implement in the way Population Health Management is meant to be, then the healthcare system would be far better and patient-centric.

Success Story
A Virginia based collaborative started a health information based project in mid-2010. Since then, 11 practices have been successful in earning recognition from NCQA (National Committee for Quality Assurance). The implemented technologies have had a profound impact on organization’s performance.

For the medical home patients, the 30-day readmission rate is below 2%.

The patient engagement scores are at 97th percentile.

With the help of the patient outreach program almost 40,000 patients have been visited as a part of preventive measures.

All this has increased the revenue by $7 million.

Barriers in the journey of Population Health Management
Currently, population health management faces a lot of challenges. The internal management and leadership quality has to be top notch so that interests remain aligned. Afterall, Population Health Management is all about team effort.

The current reimbursement model is also a concern. It has been brought forward from the 50s and now it is obsolete. Fee-for-service is anything, but cost-effective.

Patient-centric care is the heart of Population Health Management. The transition to this brings us to the biggest challenge and opportunity. Data! There is a lot of unstructured Data. True HIE can be achieved only if data are made available in a proper format. A format which doesn’t require tiring efforts from providers to get patient information. Providers should be able to gain access to health data in seconds.

The Road Ahead
We believe, the basic requirement for Population Health Management is the patient data. Everything related to a patient, such as, the outcome reports, the conditions in which the patient was born, lives, works, age and others is golden. To accurately determine the cost, activity-based costing could come in handy.

Today, the EMRs aren’t capable enough to address population health. The most basic model of population health management demands engagement on a ‘per member basis’ which can track and inform the cost of care at any point. The EMRs haven’t been designed in such a way. They just focus on the fee-for-service model.

In recent years, there has been an increased focus on population health management. Advances in the software field have been prominent and they account for the lion’s share of the expenditure on population health. I think, this could be credited to Affordable Care Act of 2010, which mandated the use of population health management solutions.

Today, the Population Health Management market is worth $14 billion and according to a report by Tractica, in five years, this value will be $31.8 billion. This is a good sign because it shows that the focus is on value-based care. There is no doubt we have miles to go, but at least now we are on the right path!

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In a recent blog post by Erik Bermudez, he asks the question about whether the Hospital EMR market is heating up or cooling down. He suggests that it’s heating up and offers this commentary as proof:

In 2015, KLAS validated that over 490 acute care hospitals were involved in an EMR contract decision of some kind, which represents an increase of almost 200% over 2014. That’s nearly 10% of the entire US hospital market making an EMR decision in 2015 alone.

We’ll see if this trend continues. No doubt there was a cooling off of the market as meaningful use matured in 2014. Given that cooling off period, it’s not really a surprise that it would start to heat up.

Eric also points out that buzzwords like population health and interoperability are dominating the conversation as opposed to EHR. I’d in the healthcare analytics buzzword to that list. These are indeed hot topics, but what’s interesting is that each of these topics really requires an EHR. You’re not likely to buy a healthcare analytics system if you don’t have an EHR. You need the data to be electronic (presumably in an EHR) to do the analytics (yes, I know there are edge cases where you don’t).

Given this dependency on EHR, we shouldn’t be surprised that many organizations are making an EMR decision. No doubt some healthcare organizations have an EMR that doesn’t support the advanced population health, interoperability and analytics initiatives they’d like to do. No doubt these advanced efforts are going to drive adoption of new EHR vendors that can support these efforts.

What do you think? Is the EHR buying market hot or cold? Let us know your thoughts in the comments.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m always on the lookout for best practices and insights that will help readers. This slide from the #HFSummit was a great look into insights into population health management. In some ways population health management is an old area, but with technology and new data sets it is also a very quickly evolving area. In case you can’t see the picture above, here are the lessons learned from population health management:

Segment high-risk populations

Harness advanced analytics

Use patient registries and medical homes

“No outcome, no income”

Go upstream

Eat your own cooking

Focus on the whole population

Meet people in their lives

Emphasize wellness and prevention

Think outside the box

Leverage technology

Partner, partner, partner

I think many of these are obvious and generic. However, a few of them are likely foreign to many healthcare organizations. As you look through the list, don’t compare yourself to other organizations. Instead, focus on where you’re at and where you want to be. We have too much comparing in hospitals and health systems and not enough leaders that are working to be the best they can be. We all don’t have to reinvent the wheel, but we also shouldn’t just follow like minions with no thought as to where we’re going.

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

There’s little doubt that healthcare organizations will continue to partner up with peers and acquire physician practices. The forces that drive healthcare network development are only intensifying as time goes by, particularly as the drive toward value-based payment moves ahead. But there’s a lot more to making such deals work than a handshake and a check. To make these deals work, it’s critical that networks become experts at population health management — and unfortunately, that’s going to be tough.

While merging health systems into ACOs or acquiring referring physicians has merit, this strategy won’t grow the steadily dropping pace of hospital admissions, notes William Faber, M.D., senior vice president of the GE Healthcare Camden Group. “Though clinically integrated networks do enlarge the patient base, one of their aims is also to reduce the percentage of admissions from that base,” making it unlikely that the networks will grow admissions, he points out.

To make a clinically integrated network successful, it certainly helps to take the initiative – to get to market more quickly than competitors – and to do a better job of controlling costs of care and demonstrating higher quality and service. Where things get stickier, however, is in managing that care across a large group. “The creation of a clinically integrated network must not be just a marketing or physician alignment strategy – it must truly enable effective population health management,” he writes.

And this, I’d argue, is where things get very tricky. Well, judge for yourself, but I’d argue that the HIT industry is ill-equipped to support these goals. Despite many years of paper-chart experimentation with population health, and several with population health technology, my sense is that the tech is far behind what it needs to be. Health IT vendors won’t get far until providers do a better job of defining what they need.

A different mindset

The truth is, this generation of EMRs is designed to track individual patients across an experience of care. While CIOs can add a layer of analytics technology to the mix, that is a far cry from creating tools that natively track population health trends. Looking at populations is simply a different mindset.

Admittedly, vendors will tell you that they’ve got the problem licked, but if they were completely candid many would have to admit that their products aren’t mature yet. Until someone creates an EMR or other basic tool which is designed, at its core, to track group health trends, I foresee more half-baked hacks than results.

What’s more, I doubt the health IT business will be able to help until it has at least an informal standard to which such products must adhere. Should such tools measure costs of care by diagnosis code? Compare such costs to national standards? Highlight patients in outpatient settings whose tests or exams suggest a crisis is about to happen? If so, which settings, and what cutoffs should be tracked for test scores? Does such a system need natural language processing to scour physician notes for trigger words, and if so which ones?

Without a doubt, medical and business executives leading integrated networks will come together and develop more answers to these questions. But until they do, health IT vendors won’t be able to help much with the population health challenge.

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

These days, virtually all hospitals and health systems are looking at ways to manage population health. Most of their approaches assume that it’s a matter of identifying the right big data tools and crunching the numbers, using the data already in-house. Doing this may be costly and time-consuming, but it can be done using existing databases, integration engines and the appropriate business analytics tools, or so the conventional wisdom holds.

However, at least one health IT leader disagrees. Adrian Zai, MD, clinical director of population informatics at Massachusetts General Hospital, argues that current tools designed to enable population health management can’t do the job effectively. “All of the health IT tools companies call population health today will be irrelevant because the data they look at can only see what goes through hospital, which is far too narrow in scope.”

Zai points out that most healthcare organizations attempt to leverage claims data in doing population health management analyses. But that approach is far from ideal, he told Healthcare IT News. Claims data, he points out, is typically one to two months old, which significantly limits the value healthcare providers can generate from the data. Also, most hospitals’ claims data only covers about 20% to 30% of the area’s population, he notes.

Instead, organizations need to study real-time data drawn from a significantly broader population if they hope to achieve population health management goals, Zai argues. For example, it’s important to look at the Medicaid population, whose members may get most of their care through community health centers. It’s also important to collect data from other consumer touch points. (Zai doesn’t specify which touch points he means, but mobile health and remote patient monitoring data come to mind immediately.)

I think Zai make some excellent points here. In particular, while achieving true real-time analysis is probably well the future for most healthcare organizations, the fresher data you can use the better. Certainly, analyzing archival data has a purpose, but to have a major impact on outcomes, it’s important to foster behavior change in the present.

However, I’d argue that few providers are ready to roll ahead with this approach. After all, to achieve his goals means establishing some new definitions as to what data should be included in population health analysis. And that’s not as simple as it sounds. (For a recent look at how providers look at population health, check out this survey from last summer.)

First, providers need to take a fresh look at how they define the term “population,” and develop a definition that takes in a more comprehensive view of patient data. Certainly, claims data analysis is start, but that by definition is limited to insured patients seen at the hospital. Zai recommends that population health management efforts embrace all patients seen at the hospital, insured or not. In other words, he’s recommending hospitals address the community in which they are physically located, not just the community of patients for whom they have provided care.

Just as importantly, hospitals and health systems need to consider how to collect, incorporate and analyze the exponentially-growing field of digital health data. While some middleware solutions offer to serve as a gateway for such data, it seems likely that providers will still need to do a lot of hands-on work to make use of these data sources.

Finally, providers need to continually improve the algorithms they use to pinpoint problems in a given population, as well as the ways in which they create actionable subsets of the population. For example, it may be appropriate to target patients by disease state today, but other ways of improving outcomes might arise, and providers’ IT solutions need to be flexible enough to evolve with the times.

Over time, the industry will evolve best practices for population health management, and definedthe IT tools best suited to accomplish reasons. And while some existing tools may work, I’d be surprised if most survive the transition.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the themes we’ve been writing a lot about recently is incorporating more social and behavioral health data into the EHR and healthcare. I think we’re at the start of a trend around using data in healthcare that is not going to stop. While we currently have more access to data than ever, it feels more like getting beat down by a wave on the beach than it does surfing a wave that provides an amazing thrill and speed. I guess I’m saying that we haven’t learned to harness the power of the wave data yet.

Much of the work we’re doing with healthcare data is around population health. I was intrigued by the findings of a population health survey done by Xerox. Here are some of the insights they shared with me:

What is population health? Definition components were ranked in the following order:

Facilitates care across the health continuum

Supports providing the highest quality of care at the lowest cost

Uses actionable insight for patient care based on a variety of data

Targets a specific population of individuals

Enables patient engagement

Is population health management necessary?

100 percent of polled providers agree that population health management is necessary as the U.S. shifts to value-based care. 81 percent indicated they “strongly agree” with the statement, while the remaining 19 percent indicated they “somewhat agree” with the statement.

What is driving population health? Driving factors were ranked in the following order:

Improved health outcomes

Improved patient relationships and experiences

Cost containment

Increased revenue opportunity

Brand and competition with others in market

What challenges exist in population health management? Challenges were ranked in the following order:

Data management and integration capabilities

Lack of financial incentives, too much risk

Poor care coordination across care providers

Creating actionable intelligence from available data

Lack of provider expertise or knowledge

Low patient engagement

When will population health management be a reality?

81 percent of polled providers believe their organizations will deliver fully scaled population health management programs within 5 years, which includes 16 percent who indicated they already are.

What this survey tells me is that we’re still trying to figure out population health. Plus, people have a really broad definition of what’s considered population health. Does that mean the word no longer has much meaning?

The final stat might be the most telling. Almost everyone believed that their organization would be able to deliver a fully scaled population health management program. Maybe there’s some arrogance bias in who participated in the survey, but I’m quite sure that we’ll have a lot more stragglers in the population health world than 18%. It’s taken us how many years to get 60% EHR adoption? I won’t be surprised if population health takes us even longer.

All of that said, the best organizations are going to leverage healthcare data to improve population health. That’s a powerful concept which isn’t going away ever.

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Though they don’t always cop to it, a goodly number of senior business leaders pay very good money — I’ve heard quotes as high as $10,000 a year — for the help of an executive coach. Part high-end consultant, part amateur therapist, executive coaches help VPs and C-suite execs make better decisions by giving them an unvarnished view of their current situation and the inspiration to carry out their most ambitious plans.

This may have something in common with bringing on a partner like, say, Deloitte, but it’s decidedly different. While executive coaches may have worked in a bigshot consulting firm like PwC, their relationship is decidedly with the individual, and a trusted one at that. The process of executive coaching sounds like a very useful one. (I’ll probably try it someday — when I have $10,000 to spare!)

The thing is, while I could be missing something, I’ve never heard so much as a hint that senior HIT executives are retaining executive coaches. It makes me wonder whether CtOs and VPs of IT still define their job largely by technical skills rather than their capacity for making strategic decisions with hospital- or system-wide implications.

The inescapable reality is that HIT execs have long outgrown supergeek status and are increasingly a key part of their healthcare organization’s future. So if they’re open for growth, HIT leaders may very well want to test out the executive coaching model, particularly in working out the following:

ACO development: While the ACO contracting and development process may be led by other departments, health IT leaders have the power to make or break these agreements by how they support then. A VP of business development may spearhead such efforts, but it’s the health IT exec who will make or break how effectively the ACO handles population health support, risk management, data analytics and more.

Managing digital health: I hardly need to remind HIT execs of this, but the most important directives as to how to work with digital health tools aren’t going to come from the CEO down, but from the CIO or VP up. With the healthcare industry just beginning to grasp the value app-laden smartphones and tablets, smart watches, sensor-laden clothing, telemedicine and other rapidly emerging technologies can bring, it’s the health IT exec who must lead the charge. And that means knowing how to solve critical business problems that extend well beyond IT’s boundaries.

EMR transformation: As hard as you’ve worked on implementing and tuning your EMR, it’d be nice to think you could stick a fork in it and consider it done. But EMRs are having new demands placed on them seemingly every day, including integration of massive volumes of wearables and other patient-generated data; number-crunching and making sense of population health data; connecting revenue cycle management functions with EMRs and much more. Deciding how to handle this spectrum of issues is the job of a business/tech thinker, not solely an IT guru.

Look, I’m not suggesting that the executive coaching is for everyone, health IT executives included. But I do believe that the right kind of executive coaching relationship could help HIT leaders to make a smoother transition into the even more critical role they are inheriting today. And anything that supports that transition is probably worth a shot.

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

It’s hard to argue that without an EMR, Accountable Care Organizations would be somewhat adrift. After all, any structure that demands a high level of coordination between multiple organizations benefits from a shared EMR backbone.

But do EMRs do a good job of managing population health, the other key responsibility of ACO clinicians? Let’s take a look at the criteria suggested by David Nash, MD, MBA, who’s Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University. Dr. Nash notes that primary care physicians in an ACO need the following:

A registry to monitor and evaluate my patients – not just individually but as a population

Relevant data on my patients who share a specific diagnosis such as hypertension or asthma

Information on how my medical management and patient outcomes compare with other local practices

Information on where my practice stands in comparison with national benchmarks

Let’s see. Do leading EMRS offer a registry to monitor patients as a group? Automatically serve up data on patients who share a specific diagnosis? Offer means of benchmarking outcomes with other local practices or national standards? No, no and no.

I can hear EMR vendors out there saying, “Hey, wait a minute. That stuff is not our problem!” And historically, they’d probably be right. After all, it’s a formidable enough job creating usable, flexible, reliable medical record analogues in digital form.

The truth is, however, that population health measures are central to the medical home, ACOs and the future of medicine generally.

My guess is that for the next few years, hospitals and large medical practices — even those who have launched an ACO — will be preoccupied enough with meeting Meaningful Use measures that they won’t be demanding more extensive population measures soon.

Still, enterprise EMR vendors will need to offer tools that meet broad population health goals eventually, as the large organizations that buy their products will soon be demanding these types of functions. The only question is when.

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

I have a bone to pick with you, Mr. Paul Cerrato of InformationWeek. Your recent column suggesting that population health management is a fad is well-argued, true. But I think you’re missing the forest for the trees.

In his column, Cerrato argues that population health management (PHM) is a trendy concept which is being pushed down physicians’ throats without docs having the tools to pull it off.

He relies partly on a report from the Institute for Health Technology Transformation, which argues that providers need not only EMRs, but also telehealth platforms, electronic registries, data management software and analytics systems to conduct PHM. There’s some truth to that.

And he notes that even existing tools, like the increasingly ubiquitous EHR, don’t have the ability to interoperate with other systems and so don’t have any information about care outside of a given provider’s practice. Again, that’s true.

But Cerrato seems to think that we’re putting the cart ahead of the horse to engage in PHM until all of that tech is in place.

Here’s where he loses me:

Physicians have been trained to provide individual care, not population care, and while PHM proponents might counter that population care is simply individual care multiplied by X, it’s more complicated than that. Many of the interventions needed to improve the health of a large population fall more into the realm of education and public safety than they do into medical practice.

While physicians may indeed have been trained to provide individual care, it’s time they embrace PHM basics. Simply screening the chronically ill patients get preventive care, if nothing else, isn’t beyond the reach of any practice with an EMR.

And as for fobbing off the population health improvement on public education, well, just tell me this: just how successful was Nancy Reagan’s “Just say no to drugs” campaign? (That one was about as hip as your grandmother’s nightgown, wasn’t it?) While some interventions may work from a governmental level, there’s a graveyard of others that never even enter the consciousness of individuals.

No, I refuse to believe that doctors can’t look at their patients as a population until they can do big-time data aggregation and the like. They need to think about their patients as a population now, especially PCPs, not only because it’s the right thing to do, but because it feeds back into daily practice to know what common patterns emerge.

The new, emerging emphasis on population health may challenge physicians, but I think they’re up to it, especially if hospitals support them in their efforts. Even if what we do now is a pale shadow of what we can do over time, there’s no excuse not to get started. PHM will be a critical part of medicine’s future, so let’s step to it.